IBHRE - International Board of Heart Rhythm Examiners Clinical Practice and Management Questions and Answers

Question 1

A 78-year-old male with persistent atrial fibrillation (CHA₂DS₂-VASc score of 4) is scheduled for a dual-chamber pacemaker implantation.
He is currently on warfarin with a therapeutic INR.
Based on the landmark BRUISE CONTROL trial, what is the most appropriate strategy for managing his anticoagulation around the time of surgery?

Accepted Answer

Continue uninterrupted warfarin, ensuring the INR is within the therapeutic range (2.0-3.0).

Answer

Stop warfarin 5 days prior, do not bridge with heparin, and resume warfarin after the procedure.

Answer

Stop warfarin 5 days prior and bridge with therapeutic low-molecular-weight heparin.

Answer

Switch to a direct oral anticoagulant (DOAC) two weeks before the procedure and hold it for 48 hours pre-procedure.

Question 2

A device manufacturer issues a notification for a specific model of ICD due to a software anomaly that could, in rare circumstances, fail to deliver therapy during a life-threatening arrhythmia. According to the FDA's medical device recall classifications, what is this situation most likely to be classified as?

Accepted Answer

A Class I recall, because there is a reasonable probability that use of the product will cause serious adverse health consequences or death.

Answer

A Class II recall, because use of the product may cause temporary or medically reversible adverse health consequences.

Answer

A Class III recall, because use of the product is not likely to cause adverse health consequences.

Answer

A market withdrawal, because the action is a minor violation not subject to legal action by the FDA.

Question 3

A remote transmission from an asymptomatic 65-year-old patient with an ICD for primary prevention (ischemic cardiomyopathy, EF 30%) is flagged for a 12-beat run of non-sustained ventricular tachycardia (NSVT) at 155 bpm. The device functioned appropriately and did not deliver therapy. What is the most appropriate next step for the reviewing clinician?

Accepted Answer

Contact the patient to assess for symptoms and schedule a routine in-person follow-up.

Answer

Reprogram the device remotely to increase the number of intervals to detect VT.

Answer

Immediately call 911 for the patient as this is a medical emergency.

Answer

Admit the patient for an electrophysiology study and possible ablation.

Question 4

During a complex ablation procedure requiring significant fluoroscopy time, which of the following actions is MOST effective for reducing the primary operator's radiation exposure, in accordance with ALARA (As Low As Reasonably Achievable) principles?

Accepted Answer

Using the lowest possible frame rate (pulse rate) for fluoroscopy.

Answer

Increasing the distance between the x-ray source (tube) and the patient.

Answer

Maximizing the use of magnification modes to improve image clarity.

Answer

Wearing two lead aprons for additional shielding.

Question 5

During a transseptal puncture for a left atrial ablation, the patient suddenly becomes hypotensive (BP 85/50 mmHg), tachycardic, and their jugular venous pressure becomes markedly elevated. On the fluoroscopy monitor, the cardiac silhouette appears enlarged. This clinical presentation is most consistent with which procedural complication?

Accepted Answer

Cardiac tamponade.

Answer

A vasovagal reaction.

Answer

An air embolism.

Answer

Aortic root puncture.

Question 6

Which of the following elements is NOT a mandatory component of the informed consent process for an electrophysiology procedure like a catheter ablation or device implant?

Accepted Answer

A guarantee of a successful outcome without complications.

Answer

A discussion of the nature of the procedure and its expected benefits.

Answer

A presentation of viable alternatives, including the option of no treatment.

Answer

A description of the potential material risks and common complications.